Case Note Sample Narratives

Case Narrative #5

This case narrative focuses on the care I provided for a 45-year-old African American male who was admitted to the emergency department with complaints of flu-like symptoms. The patient's primary insurance is Healthfirst. This case incorporates the following doctoral competency objectives.

Objective 4: Use ethical decision-making to promote the well-being of individuals, families, health care professionals in local, national, and international communities

Objective 7: Demonstrate safe, effective assessment, planning, implementation, and evaluation skills in caring for individuals and groups while working in interprofessional collaborative relationships

Objective 5: Utilize evidence-based practice recommendations and professional standards of care to promote health, prevent disease and improve the health status of individuals, families, groups, communities, and populations

DNP role: I am a certified family nurse practitioner and a DNP resident assessing this patient who is on the Cardiology team. Prior N.P admitted the patient. 

Setting: Large Urban teaching hospital in NYC- emergency department

Reason for Encounter: Flu-like symptoms

Informant: Patient

History of Present Illness: S.A. is a 45-year-old African American male with no medical history who presents to the emergency department for palpitations. The patient endorsed having a runny nose, cough, low-grade fever, and palpitations for one week. Flu-like symptoms have progressively gotten worse, and he felt as if he was going to pass out. Coughing and runny nose are associated with some shortness of breath and dizziness at times. Upon arrival to the emergency department, telemetry showed a heart rate of 140s, Blood pressure of 90/60, and EKG irregular rate and rhythm indicative of Atrial Fibrillation. Due to a new afib diagnosis, he was referred to an Electrophysiologist, and Cardioversion was planned.

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Current Medications:

Multivitamin one tablet by mouth daily

Review of Systems:

General: S.A. is a cooperative, 46-year-old African American male who appears to be a little nervous about his symptoms. He is alert and oriented to place, person and time. He maintains eye contact throughout the interview and physical exam.  

Head/Eyes/Ears/Nose/Throat: Reports dizziness, no headaches. No change in vision. The exam is positive for sinus or nasal congestion.

Neck: Full range of motion

Cardiovascular: Heart racing, denies chest pain, denies leg swelling

Respiratory: Positive for shortness of breath and moderate cough

Gastrointestinal: Reports recent weight loss and decreased appetite. Denies vomiting, diarrhea, or constipation

Genitourinary: Denies pain or burning with urination, urinary frequency, urinary urgency, unusual vaginal discharge, or vaginal pain.

Physical Examination:

General: Ambulatory, slim male who appears to be his stated age.

Vitals Signs:

99.6 Fahrenheit oral, Blood pressure 90/60, heart rate 140 beats/minute, respiratory rate 22 breaths per minute, pulse oximetry 95 % on room air, pain assessment 0 on a scale 1-10 scale

Chest: Respirations even and unlabored. No accessory muscle use. Lungs clear bilaterally throughout. 

Heart: Tachycardia, regular rate and rhythm no murmurs. Skin warm and dry. Capillary refill is less than two seconds to fingertips—radial pulses 2+/0-4+ bilaterally.

Neck: Thyroid normal size, no carotid bruits

Abdomen: Flat, soft, non-distended. No guarding, no rebound tenderness. No mass palpated. Bowel sounds are active in all four quadrants upon auscultation.

Genitourinary: Shaven groomed external genital region. No lesions or abrasions to the external genitalia.

Neurological: Awake, alert, oriented to person, place, time, and situation.

Impression: S.A. is a 46-year-old African American male with no medical history who presents to the emergency department for flu-like symptoms, palpitations, and mild shortness of breath. He endorsed having flu-like symptoms for one week. Palpitations and flu-like symptoms have progressively gotten worse, and he felt as if he was going to pass out. As a result, he decided to seek emergent care. EKG shows irregular rate and rhythm that is indicative of atrial fibrillation.

The differential diagnosis

1. Palpitations (R00.2)   

Palpitations is a possible diagnosis in this case because of the patient's history of present illness, physical examination findings, and review of symptoms. The patient described a year-long history of palpitations that has gotten progressively worse with time. Palpitations can be caused by cardiac symptoms such as atrial fibrillation, atrial premature contractions, autonomic dysfunction, supraventricular tachycardia, and non-cardiac causes such as alcohol, anxiety, stress, anemia, and caffeine (Wexler et al., 2017). Palpitations is a possible diagnosis because the patient's physical examination revealed nervousness and anxiety about her symptoms. Anxiety, panic attacks, and somatization disorder can activate the autonomic nervous system and cause palpitations (Wexler et al., 2017). The patient's palpitations can be attributed to underlying anxiety observed during the physical examination. Moreover, the physical examination revealed a heart rate of 150 beats/minute, suggestive of arrhythmia and supportive of the diagnosis of palpitations. Another finding supporting the diagnosis of palpitations is the report of her heart racing on review of systems.

Cardiac impulses are transmitted down the right atrium wall to the atrial ventricular node and distributed through the His-Purkinje system with subsequent ventricular depolarization. Arrhythmias are caused by disruptions of the cardiac impulse along the pathways. Patients can experience a floppy sensation in their chest or become aware of fast, regular, slow, or irregular palpitations (Wexler et al., 2017). (level of evidence 5).  

2. COVID-19 infection (ICD 10 code)

Covid-19 is mainly indicated by the presence of fatigue, shortness of breath, cough, and fever (Wang et al., 2020). Some of these symptoms, including Coughing and runny nose associated with some shortness of breath and dizziness at the time, were reported by the patient. Thus, the diagnosis. 

(Level of evidence 2a)

3. Atrial fibrillation (I48.91, unspecified atrial fibrillation)

Atrial fibrillation is a supraventricular tachyarrhythmia characterized by irregular and fast cardiac contractions and consequential impaired blood flow. Atrial fibrillation is a possible diagnosis because of the patient's symptoms, and the telemetry findings are suggestive of atrial fibrillation. The consequences of atrial fibrillation include dyspnea, fatigue, palpitations, syncope, and hypotension (Zeiser et al., 2020). The patient's symptoms of palpitations that have gotten progressively worse, reports of shortness of breath, and near-syncope episodes are suggestive of atrial fibrillation. On arrival to the emergency department, the telemetry findings showed a heart rate of the 140's p waves not present. Therefore a diagnosis of atrial fibrillation is likely. Atrial fibrillation is a supraventricular tachycardia that may be associated with a marked reduction in cardiac output because of impaired atrial contraction. Episodes of atrial fibrillation progressively increase with duration and frequency. The patient's blood pressure of 90/60 is suggestive of reduced cardiac output from atrial fibrillation. The patient's heart rate in the 140s is suggestive of supraventricular tachycardia. The characteristic electrocardiogram (ECG) pattern for atrial fibrillation includes an absence of distinct repeating P waves, irregular R-R intervals, and irregular atrial activity. Physical examination findings of atrial fibrillation include an irregular heart rate without a repeating pattern (Wexler et al., 2017).

Atrial fibrillation is a supraventricular tachyarrhythmia associated with uncoordinated atrial activation and ineffective contraction with hemodynamic consequences ranging from asymptomatic to palpitations, syncope, dyspnea, and heart failure hypotension, and fatigue. Atrial fibrillation may be associated with a worsening underlying cardiac condition because atrial fibrillation causes or results in deterioration or contributes to the worsening illness (January et al., 2019).  

Oxford Centre for Evidence-Based Medicine Level of Evidence 2a

IC10 Codes:

Palpitations: R00.2

Atrial fibrillation: I48.91

COVID 19 infection:

Plan: 

1. The plan is to perform serial ECGs to identify rate and rhythm control. The patient presented with palpitations that have gotten progressively worse and reported symptoms of shortness of breath and presyncope episodes suggestive of atrial fibrillation. The rationale for the serial ECGs is that serial ECGs have been shown to be as effective as a 24-Holter monitor in detecting paroxysmal atrial fibrillation (Huang et al., 2021).

Oxford Centre for Evidence-Based Medicine Level of Evidence 2a

2. The patient had a heart rate in the 140s on telemetry in the emergency room and a heart rate of 150 during the physical examination. The plan for this patient includes Beta-blockers and anticoagulation. Better blockers facilitate rapid rate control by reducing resting and exercise ventricular rates (Lampart et al., 2020).

Oxford Centre for Evidence-Based Medicine Level of Evidence 3b

3. The plan includes Cardioversion. Since there was a noted tachycardia present on the patient's results, conducting Cardioversion can help achieve normal heart rhythm (Dundik et al., 2017). 

Oxford Centre for Evidence-Based Medicine Level of Evidence 3b

Diagnostics Tests

1. An EKG was done that showed a heart rate of 140 beats per minute with irregular rhythm and no P waves present. The rationale for performing the EKG was to provide information about the type of supraventricular arrhythmia. 

A 12-lead ECG obtained when the person is experiencing tachycardia and during sinus rhythm may show the cause of tachycardia (Kodia et al., 2020).

Oxford Centre for Evidence-Based Medicine Level of Evidence 3a

2. An echocardiogram was done that showed a left ventricular ejection fraction (LVEF) of 70 % with no wall motion abnormalities. The rationale for the echocardiogram was to evaluate wall motion, left ventricular function, and septal thickness to rule out congenital heart defects and cardiomyopathy as the etiology for the arrhythmia.

Some individuals with certain congenital heart defects and cardiomyopathy may have abnormal ventricular activation and atrial enlargement that causes "pseudo-excitation," mimicking a WPW pattern with a short P.R. and widened QRS from hypertrophy in individuals with cardiomyopathy (Chhabra et al., 2021).

Oxford Centre for Evidence-Based Medicine Level of Evidence 5

Laboratory Test Results

Labs	Values	Normal Range
CBC
WBC	5, 000	4,000-11,000
RBC	4.72	4.35 to 5.65
HGB	13.5	12-18
HCT	43.1	38-54%
Platelets	150,000	150,000-400,000
Neutrophils	46%	45-75%
Band Neutrophils	5%	0-5%
Sodium	137	135-145
Potassium	4	3.5-5.1
Chloride	100	96-106
C02	23	23-29
Glucose	106	70-110
BUN	14	7-20
Creatinine	0.65	0.6-1.2
GFR	>60	90-120
Lactic Acid	1.1	0.5-2.2

SARS COVID- negative

Referrals:

Electrophysiology was consulted, and plan is for Cardioversion. 

Electrophysiology was consulted because the patient has afib on ECG and is symptomatic with palpitations, presyncope, and dizziness. The patient is symptomatic, and an electrophysiology consultation to evaluate him for the need for invasive intervention is warranted. Since there was a noted tachycardia present on the patient's results, conducting Cardioversion can help achieve normal heath rhythm (Dundik et al., 2017). Similarly, The rationale for consulting electrophysiology: To help in assessing the heart activities and electrical systems. 

Oxford Centre for Evidence-Based Medicine Level of Evidence 3b

Counseling and Education:

Explained to patient risk and benefits to Cardioversion

Explained the reason for beta-blockers and anticoagulation

Medications

medication	Mode of action	Clinical use	Side effects
Metoprolol Tartrate 50 mg bid PO	blocking the effects of the hormone epinephrine	Treating hypertension and irregular heart rates	Dizziness.  Bleeding from nose or gums. Difficulty breathing, wheezing
Eliquis 5 mg bid	inhibits prothrombinase activity and free and clot-bound factor Xa	Preventing blood clot formation	Depression. Dry mouth. stomach pain Nausea. .

References

Chhabra, L., Goyal, A., & Benham, M. D. (2021). Wolff Parkinson White Syndrome. In StatPearls. StatPearls Publishing.

Dudink, E., Essers, B., Holvoet, W., Weijs, B., Luermans, J., Ramanna, H., Liem, A., van Opstal, J., Dekker, L., van Dijk, V., Lenderink, T., Kamp, O., Kulker, L., Rienstra, M., Kietselaer, B., Alings, M., Widdershoven, J., Meeder, J., Prins, M., van Gelder, I., … Crijns, H. (2017). Acute cardioversion vs a wait-and-see approach for recent-onset symptomatic atrial fibrillation in the emergency department: Rationale and design of the randomized ACWAS trial. American heart journal, 183, 49–53. https://doi.org/10.1016/j.ahj.2016.09.009

Huang, W. Y., Lee, M., Sung, S. F., Tang, S. C., Chang, K. H., Huang, Y. S., Lee, J. D., Lee, T. H., Jeng, J. S., Chung, C. M., Wu, Y. L., Hsieh, T. T., & Ovbiagele, B. (2021). Atrial fibrillation trial to evaluate real-world procedures for their utility in helping to lower stroke events: A randomized clinical trial. International journal of stroke: official journal of the International Stroke Society, 16(3), 300–310. https://doi.org/10.1177/1747493020938297

Kotadia, I. D., Williams, S. E., & O'Neill, M. (2020). Supraventricular tachycardia: An overview of diagnosis and management. Clinical medicine (London, England), 20(1), 43–47. https://doi.org/10.7861/clinmed.cme.20.1.3

Lampert, R., Burg, M. M., Jamner, L. D., Dziura, J., Brandt, C., Li, F., Donovan, T., & Soufer, R. (2019). Effect of β-blockers on triggering of symptomatic atrial fibrillation by anger or stress. Heart rhythm, 16(8), 1167–1173. https://doi.org/10.1016/j.hrthm.2019.03.004

Zaiser, E., Sehnert, A. J., Duenas, A., Saberi, S., Brookes, E., & Reaney, M. (2020). Patient experiences with hypertrophic cardiomyopathy: a conceptual model of symptoms and impacts on quality of life. Journal of patient-reported outcomes, 4(1), 102. https://doi.org/10.1186/s41687-020-00269-8

Wang, D., Hu, B., Hu, C., Zhu, F., Liu, X., Zhang, J. & Peng, Z. (2020). Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama, 323(11), 1061-1069. https://doi.org/10.1001/jama.2020.1585

Wexler, R. K., Pleister, A., & Raman, S. V. (2017). Palpitations: evaluation in the primary care setting. American family physician, 96(12), 784-789. https://www.aafp.org/afp/2017/1215/p784.html